钝性脑血管损伤的评估与管理：东部创伤外科学会的实践管理指南。
Evaluation and management of blunt cerebrovascular injury: A practice management guideline from the Eastern Association for the Surgery of Trauma.
机构信息
From the Division of Trauma/Acute Care Surgery/Surgical Critical Care, Department of Surgery (D.Y.K.), Harbor-UCLA Medical Center, David Geffen School of Medicine at UCLA, Torrance; Trauma Surgery Department, Scripps Memorial Hospital La Jolla (W.B.), La Jolla, California; Department of Trauma and Burn Surgery, Stroger Hospital of Cook County (F.B.), Rush University, Chicago, Illinois; Department of Surgery (S.B.), University of Florida, Gainesville, Florida; Department of Surgery, Jacobi Medical Center (E.C.), Bronx, New York; Department of Surgery, MetroHealth Medical Center (J.A.C., J.J.C.), Cleveland, Ohio; Department of Surgery, UNLV School of Medicine (D.F.), Las Vegas, Nevada; Division of Trauma, Emergency Surgery, and Surgical Critical Care, School of Medicine (R.J.), Stony Brook University, Stony Brook, New York; Department of Surgery, University of Florida College of Medicine - Jacksonville (A.K., B.Y.), Jacksonville, Florida; Department of Surgery, Duke University (G.K.), Durham, North Carolina; Department of Surgery, Western Virginia University (U.K.), Morgantown, West Virginia; Department of Surgery (S.K.), Chippenham-Johnston Willis Medical Center, NorthStar Trauma Surgery, Richmond, Virginia; Department of Surgery, Riverside Community Hospital (D.P.), Riverside, California; Division of Trauma and Critical Care, Department of Surgery, Harborview Medical Center (B.R.H.R.), University of Washington, Seattle, Washington; Division of Acute Care and Trauma Surgery, Department of Surgery, Rochester University Medical Center (N.S.), Rochester, New York; and Department of Surgery, University of Maryland Medical Center (R.T.), Baltimore, Maryland.
出版信息
J Trauma Acute Care Surg. 2020 Jun;88(6):875-887. doi: 10.1097/TA.0000000000002668.
BACKGROUND
Blunt cerebrovascular injuries (BCVIs) are associated with significant morbidity and mortality. This guideline evaluates several aspects of BCVI diagnosis and management including the role of screening protocols, criteria for screening cervical spine injuries, and the use of antithrombotic therapy (ATT) and endovascular stents.
METHODS
Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology, a taskforce of the Practice Management Guidelines Committee of the Eastern Association for the Surgery of Trauma performed a systematic review and meta-analysis of currently available evidence. Four population, intervention, comparison, and outcome questions were developed to address diagnostic and therapeutic issues relevant to BCVI.
RESULTS
A total of 98 articles were identified. Of these, 23 articles were selected to construct the guidelines. In these studies, the detection of BCVI increased with the use of a screening protocol versus no screening protocol (odds ratio [OR], 4.74; 95% confidence interval [CI], 1.76-12.78; p = 0.002), as well as among patients with high-risk versus low-risk cervical spine injuries (OR, 12.7; 95% CI, 6.24-25.62; p = 0.003). The use of ATT versus no ATT resulted in a decreased risk of stroke (OR, 0.20; 95% CI, 0.06-0.65; p < 0.0001) and mortality (OR, 0.17; 95% CI, 0.08-0.34; p < 0.0001). There was no significant difference in the risk of stroke among patients with Grade II or III injuries who underwent stenting as an adjunct to ATT versus ATT alone (OR, 1.63; 95% CI, 0.2-12.14; p = 0.63).
CONCLUSION
We recommend using a screening protocol to detect BCVI in blunt polytrauma patients. Among patients with high-risk cervical spine injuries, we recommend screening computed tomography angiography to detect BCVI. For patients with low-risk risk cervical injuries, we conditionally recommend performing a computed tomography angiography to detect BCVI. We recommend the use of ATT in patients diagnosed with BCVI. Finally, we recommend against the routine use of endovascular stents as an adjunct to ATT in patients with Grade II or III BCVIs.
LEVEL OF EVIDENCE
Guidelines, Level III.
背景
钝性脑血管损伤（BCVI）与显著的发病率和死亡率相关。本指南评估了 BCVI 诊断和管理的几个方面，包括筛查方案的作用、颈椎损伤的筛查标准，以及抗血栓治疗（ATT）和血管内支架的使用。
方法
使用推荐评估、制定和评估（GRADE）方法，东部创伤外科学会实践管理指南委员会的一个工作组对目前可用的证据进行了系统评价和荟萃分析。为了解决与 BCVI 相关的诊断和治疗问题，制定了四个人群、干预、比较和结局问题。
结果
共确定了 98 篇文章。其中，选择了 23 篇文章来制定指南。在这些研究中，与不使用筛查方案相比，使用筛查方案可增加 BCVI 的检出率（比值比 [OR]，4.74；95%置信区间 [CI]，1.76-12.78；p = 0.002），以及在高风险与低风险颈椎损伤患者中（OR，12.7；95% CI，6.24-25.62；p = 0.003）。与不使用 ATT 相比，使用 ATT 可降低卒中（OR，0.20；95% CI，0.06-0.65；p < 0.0001）和死亡率（OR，0.17；95% CI，0.08-0.34；p < 0.0001）的风险。在接受 ATT 联合支架治疗的 II 级或 III 级损伤患者与单独接受 ATT 治疗的患者之间，卒中风险无显著差异（OR，1.63；95% CI，0.2-12.14；p = 0.63）。
结论
我们建议在钝性多发伤患者中使用筛查方案来检测 BCVI。对于高风险颈椎损伤患者，我们建议行 CT 血管造影以检测 BCVI。对于低风险颈椎损伤患者，我们有条件地建议行 CT 血管造影以检测 BCVI。我们建议对诊断为 BCVI 的患者使用 ATT。最后，我们建议在 II 级或 III 级 BCVI 患者中，不常规使用血管内支架作为 ATT 的辅助治疗。
证据水平
指南，III 级。
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